Nasal Ryle Tube Insertion in Sphenoid Fracture
Do not insert a nasogastric (Ryle) tube nasally in patients with sphenoid fractures—use the oral route instead. Sphenoid fractures are a type of skull base fracture, and multiple guidelines and case reports confirm that nasal tube insertion in this setting carries a risk of intracranial placement with potentially fatal consequences.
Evidence Supporting Oral Route in Skull Base Fractures
The American Heart Association guidelines explicitly state that in the presence of known or suspected basal skull fracture, an oral airway is preferred over nasal insertion 1. This recommendation extends to all nasal instrumentation, including nasogastric tubes. The American Society for Metabolic and Bariatric Surgery reinforces this by recommending oral gastric tubes specifically for patients with maxillofacial trauma, particularly those involving midface fractures 2.
The sphenoid bone is part of the skull base, and fractures in this region create a direct communication between the nasal cavity and intracranial space. Case reports document inadvertent intracranial placement of nasogastric tubes through the cribriform plate and sphenoid sinus in patients with skull base fractures, with associated high morbidity and mortality 3, 4, 5.
Clinical Algorithm for Tube Placement Decision
When gastric decompression or enteral feeding is needed in a patient with sphenoid fracture:
- Confirm the presence of skull base fracture (including sphenoid fracture) through CT imaging before any nasal instrumentation 4
- Select the oral route (orogastric tube) as the primary approach in all confirmed or suspected skull base fractures 1, 2
- Verify tube placement radiographically before initiating feeding, regardless of insertion route 6
- Consider percutaneous gastrostomy (PEG) if feeding needs are anticipated to exceed 4 weeks 6, 2
Mechanism of Intracranial Injury Risk
The sphenoid sinus roof and ethmoid fovea are particularly vulnerable structures. Research in cadaver models demonstrates that even after endoscopic sinus surgery (which creates less disruption than fractures), nasogastric tubes can penetrate the fovea ethmoidalis in 7.7% of attempts and easily enter the sphenoid sinus 7. In the setting of acute fractures with disrupted bony architecture, this risk is substantially higher.
Multiple case reports confirm that intracranial tube placement through skull base fractures is associated with patient death, though the exact causal relationship varies 4. One documented case showed a nasogastric tube passing through the lamina cribrosa of the ethmoid bone into the brain parenchyma, with the patient expiring from complications 5.
Practical Considerations for Orogastric Tube Use
- Orogastric tubes are equally effective for gastric decompression and feeding as nasogastric tubes 2
- Secure fixation is critical—40-80% of gastric tubes become dislodged without proper securement 2
- Orogastric tubes may be more difficult to secure in conscious patients and may cause slightly more discomfort than nasogastric tubes, but this is vastly preferable to the risk of intracranial placement 2
- Standard tube sizes (8-12 French for adults) apply to both routes 6
Common Pitfall to Avoid
Never rely on the absence of obvious CSF leak or the patient's clinical stability as reassurance that nasal tube insertion is safe in skull base fractures. Fractures may not be immediately apparent on initial examination, and intracranial penetration can occur even with seemingly intact anatomy 3, 5. The Advanced Trauma Life Support protocol specifically recommends orogastric rather than nasogastric tubes in patients with basal skull fractures for this reason 4.
Special Circumstances
If the patient has contraindications to oral tube placement (such as severe oral trauma or trismus preventing oral access), consider early percutaneous gastrostomy or surgical jejunostomy rather than attempting nasal insertion 1, 6. For patients requiring prolonged nutritional support beyond 4 weeks, PEG placement is preferred over either nasal or oral tubes 6, 2.